Provider Demographics
NPI:1366856569
Name:GWAK, BOWHEE SOHN
Entity Type:Individual
Prefix:
First Name:BOWHEE
Middle Name:SOHN
Last Name:GWAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 POWELL AVE SW
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-2908
Mailing Address - Country:US
Mailing Address - Phone:425-277-1311
Mailing Address - Fax:
Practice Address - Street 1:10414 BEARDSLEE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3205
Practice Address - Country:US
Practice Address - Phone:425-486-0658
Practice Address - Fax:425-487-6761
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105225207Q00000X
WA60773048207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2086646Medicaid